Cirrhosis

Introduction

Cirrhosis is a condition in which the liver slowly deteriorates and is unable to function normally due to chronic, or long lasting, injury. Scar tissue replaces healthy liver tissue and partially blocks the flow of blood through the liver.

The liver is the body’s largest internal organ. The liver is called the body’s metabolic factory because of the important role it plays in metabolism—the way cells change food into energy after food is digested and absorbed into the blood.

A healthy liver is necessary for survival. The liver can regenerate most of its own cells when they become damaged. However, if injury to the liver is too severe or long lasting, regeneration is incomplete, and the liver creates scar tissue. Scarring of the liver, also called fibrosis, may lead to cirrhosis.

Many people with cirrhosis have no symptoms in the early stages of the disease. However, as the disease progresses, a person may experience the following symptoms: fatigue, or feeling tired, weakness, itching, loss of appetite, weight loss, nausea, bloating of the abdomen from ascites, swelling in the feet, ankles & jaundice.

Diagnosis

Your doctor usually diagnoses cirrhosis based on the presence of conditions that increase its likelihood, such as heavy alcohol use or obesity, and symptoms. Your doctor may test for cirrhosis based on the presence of these conditions alone because many people do not have symptoms in the early stages of the disease. A health care provider may confirm the diagnosis with a medical and family history, physical exam, blood test, imaging tests & liver biopsy.

Ultrasound or CECT: These scans are commonly used to show signs of advanced cirrhosis, such as irregularities in the liver surface, gastric varices, and splenomegaly. These tests can also detect signs of complications, such as ascites and liver cancer.

Elastography: Elastography is also called liver stiffness measurement, uses either ultrasound or MRI to measure the stiffness of the liver. Scar tissue increases the stiffness of the liver. Elastography can show how much scarring is present with some reliability.

Liver Biopsy: A liver biopsy can confirm the diagnosis of cirrhosis; however, a person does not always need this test. A biopsy is done if the result might help determine the cause or affect treatment.

Complications

As the liver fails, complications may develop. In some people, complications may be the first signs of the disease. Complications of cirrhosis may include the following:

Portal Hypertension:The portal vein carries blood from the stomach, intestines, spleen, gallbladder, and pancreas to the liver. In cirrhosis, scar tissue partially blocks the normal flow of blood, which increases the pressure in the portal vein. This condition is called portal hypertension. Portal hypertension is a common complication of cirrhosis. This condition may lead to other complications, such as fluid buildup leading to edema and ascites, enlarged blood vessels, called varices, in the esophagus, stomach, or both an enlarged spleen, called splenomegaly & mental confusion due to a buildup of toxins that are ordinarily removed by the liver, a condition called hepatic encephalopathy

Elastography: Elastography is also called liver stiffness measurement, uses either ultrasound or MRI to measure the stiffness of the liver. Scar tissue increases the stiffness of the liver. Elastography can show how much scarring is present with some reliability.

Bleeding (Varices): Portal hypertension may cause enlarged blood vessels in the esophagus, stomach, or both. These enlarged blood vessels, called esophageal or gastric varices, cause the vessel walls to become thin and blood pressure to increase, making the blood vessels more likely to burst. If they burst, serious bleeding can occur in the esophagus or upper stomach, requiring immediate medical attention.

Splenomegaly: Portal hypertension may cause the spleen to enlarge and retain white blood cells and platelets, reducing the numbers of these cells and platelets in the blood. A low platelet count may be the first evidence that a person has developed cirrhosis.

Abnormal Behaviour: Its medically known as Hepatic encephalopathy. A failing liver cannot remove toxins from the blood, so they eventually accumulate in the brain. The buildup of toxins in the brain is called hepatic encephalopathy. This condition can decrease mental function and cause stupor and even coma. Stupor is an unconscious, sleeplike state from which a person can only be aroused briefly by a strong stimulus, such as a sharp pain. Coma is an unconscious, sleeplike state from which a person cannot be aroused. Signs of decreased mental function include confusion, personality changes, memory loss, trouble concentrating & a change in sleep habits

Metabolic bone diseases: Some people with cirrhosis develop a metabolic bone disease, which is a disorder of bone strength usually caused by abnormalities of vitamin D, bone mass, bone structure, or minerals, such as calcium and phosphorous. Osteopenia is a condition in which the bones become less dense, making them weaker. When bone loss becomes more severe, the condition is referred to as osteoporosis. People with these conditions are more likely to develop bone fractures.

Gallstones and bile duct stones: If cirrhosis prevents bile from flowing freely to and from the gallbladder, the bile hardens into gallstones. Symptoms of gallstones include abdominal pain and recurrent bacterial cholangitis—irritated or infected bile ducts. Stones may also form in and block the bile ducts, causing pain, jaundice, and bacterial cholangitis.

Bruising and bleeding: When the liver slows the production of or stops producing the proteins needed for blood clotting, a person will bruise or bleed easily.

Insulin resistance and type 2 diabetes: Cirrhosis causes resistance to insulin. The pancreas tries to keep up with the demand for insulin by producing more; however, extra glucose builds up in the bloodstream, causing type 2 diabetes.

Liver cancer: Liver cancer is common in people with cirrhosis. Liver cancer has a high mortality rate. Current treatments are limited and only fully successful if a health care provider detects the cancer early, before the tumor is too large. For this reason, health care providers should check people with cirrhosis for signs of liver cancer every 6 to 12 months. Health care providers use blood tests, ultrasound, or both to check for signs of liver cancer.

Other complications: Cirrhosis can cause immune system dysfunction, leading to an increased chance of infection. Cirrhosis can also cause kidney and lung failure, known as hepatorenal and hepatopulmonary syndromes.

Treatment

Treatment for cirrhosis depends on the cause of the disease and whether complications are present. In the early stages of cirrhosis, the goals of treatment are to slow the progression of tissue scarring in the liver and prevent complications. As cirrhosis progresses, a person may need additional treatments and hospitalization to manage complications. Treatment may include the following:

Avoiding Alcohol

Avoid unknown medicines (herbs etc)

Viral Hepatitis A & B Vaccination and Screening of Viral hepatitis C

Treating Causes of Cirrhosis: Your doctor can treat some causes of cirrhosis, for example, by prescribing antiviral medications for hepatitis B and C, corticosteroids and other medications for auto-immune hepatitis, bile flow drugs (ursadiol) to relieve jaundice etc.

Treating Symptoms and Complications of Cirrhosis

Varices & Portal hypertension: Beta-blockers can lower the pressure in varices and reduce the likelihood of bleeding. Bleeding in the stomach or esophagus requires an immediate upper endoscopy. This procedure involves using an endoscope—a small, flexible tube with a light—to look for varices & band ligation is one, a procedure that involves placing a special rubber band around the varices that causes the tissue to die and fall off.

Ascites Your doctor providers prescribe diuretics—medications that remove fluid from the body—to treat edema and ascites. Your doctor may remove large amounts of ascitic fluid from the abdomen and check for infection (spontaneous bacterial peritonitis).

Hepatic Encephalopathy A health care provider treats hepatic encephalopathy by cleansing the bowel with lactulose, a laxative given orally or as an enema—a liquid put into the rectum. A health care provider may also add antibiotics to the treatment.

Hepatorenal syndrome Some people with cirrhosis who develop hepatorenal syndrome must undergo regular dialysis treatment, which filters wastes and extra fluid from the body by means other than the kidneys. People may also need medications to improve blood flow through the kidneys.

Liver Cancer A health care provider may recommend screening tests every 6 to 12 months to check for signs of liver cancer. Screening tests can find cancer before the person has symptoms of the disease. Cancer treatment is usually more effective when its diagnosed early. Health care providers use blood tests, ultrasound, or both to screen for liver cancer in people with cirrhosis. He or she may treat cancer with a combination of surgery, radiation, and chemotherapy.

Its time for transplant: Your doctor may advice a liver transplant when cirrhosis leads to liver failure or treatment for complications is ineffective. Liver transplantation is surgery to remove a diseased or an injured liver and replace it with a healthy whole liver or part of a liver from another person, called a donor.

Outcome

Compensated Cirrhosis: If Cirrhosis is don’t cause any complications like jaundice, bleeding, ascites or encephalopathy, is medically labelled as “Compensated cirrhosis”. Cirrhosis can remain compensated for many years. The transition from compensated to decompensated cirrhosis ( ie. Cirrhosis with any of complications) occurs at a rate of approximately 5 to 7% per year. The median survival of compensated cirrhotics has been reported to be 9 to 12 years.

Decompensated cirrhosis means person with cirrhosis has jaundice, ascites, variceal hemorrhage, or hepatic encephalopathy. In general, survival is poor in patients with decompensated cirrhosis and they should be considered for liver transplantation. Patients with ascites and variceal hemorrhage have a reported 1-year survival rate of less than 50%.

Diet

A healthy diet is important in all stages of cirrhosis because malnutrition is common in people with this disease. If ascites develops, take sodium-restricted diet. A person with cirrhosis should not eat raw shellfish, which can contain a bacterium that causes serious infection.

Risks and side effects of surgery

There are risks that go with any type of medical procedure and surgery is no longer an exception. Success of surgery depends upon 3 factors: type of disease/surgery, experience of surgeon and overall health of patients. What’s important is whether the expected benefits outweigh the possible risks.

Doctors have been performing surgeries for a very long time. Advances in surgical techniques and our understanding of how to prevent infections have made modern surgery safer and less likely to damage healthy tissues than it has ever been. Still, there’s always a degree of risk involved, no matter how small. Different procedures have different kinds of risks and side effects. Be sure to discuss the details of your case with our health care team, who can give you a better idea about what your actual risks are. During surgery, possible complications during surgery may be caused by the surgery itself, the drugs used (anesthesia), or an underlying disease. Generally speaking, the more complex the surgery is the greater the risk. Complications in major surgical procedures include:

Complications related to Anaesthesia:Reactions to drugs used (anesthesia) or other medicines. Although rare, these can be serious because they can cause dangerously low blood pressures.

Lung: Pneumonia, Atelectasis (collapse of lung), effusion (fluid in chest) can occur, especially in patients with reduced lung function, such as smokers. Doing deep breathing exercises as soon as possible after surgery helps lessen this risk.

Thrombosis (blood clot) in leg & embolism (blood clot) in lung. Blood clots can form in the deep veins of the legs after surgery, especially if a person stays in bed for a long time. Such a clot can become a serious problem if it breaks loose and travels to another part of the body, such as a lung. This is a big reason why you will be encouraged to get out of bed to sit, stand, and walk as soon as possible.

Post-resection Liver failure: It happens upto 15% cases, despite careful selection of case. Appearance of jaundice, progressive deepening of jaundice and change in behaviour of patient are alarming symptoms. It usually invites more complications after surgery and can progress to death.

Bile leak

Bleed

Complications related to Major Surgery

Infection: Infection at the site of the wound, lung and urinary infection. Infection risk is more if intestine is perforated before surgery, operated for colon and rectum, stent in placed in bile duct to relieve jaundice or intestinal joint is leaking.

Bleeding: The risk of bleeding during or after surgery is more if patient taking blood thinning medicine till day of surgery or having liver dysfunction. Bleeding during surgery that may cause you to need blood transfusions. There is a risk of certain problems with transfusions, some of them serious. Still, some operations involve a certain amount of controlled blood loss. Bleeding can happen either inside the body (internally) or outside the body (externally). It can occur if a blood vessel sealed during surgery opens up or if a wound opens up. Serious bleeding may cause the person to need another operation to find the source of the bleeding and stop it.